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Year 3 - GP > SLA 17 - Asthma and COPD > Flashcards

SLA 17 - Asthma and COPD Flashcards

1
Q

Define what is meant by tidal volume.

A

The volume that enters and leaves the lungs with each breath, from a normal quiet inspiration to a normal quiet expiration.

Average ~0.5L.

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2
Q

Define what is meant by inspiratory reserve volume.

A

The extra volume that can be inspired above tidal volume, from a normal quiet inspiration to maximum inspiration.

Average ~2.5L.

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3
Q

Define what is meant by expiratory reserve volume.

A

The extra volume that can be exhaled below tidal volume, from a normal quiet expiration to maximum expiration.

Average ~1.5L.

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4
Q

Define what is meant by residual volume.

A

The volume remaining after maximum expiration.

Average ~1.5L.

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5
Q

Define what is meant by vital capacity.

A

The volume that can be exhaled after maximum inspiration.

Expiratory reserve volume + tidal volume + inspiratory reserve volume

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6
Q

Define what is meant by inspiratory capacity.

A

The volume that can be inhaled from quiet expiration to maximum inspiration.

Tidal volume + inspiratory reserve volume

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7
Q

Define what is meant by functional residual capacity.

A

The volume remaining after quiet expiration.

Residual volume + expiratory reserve volume

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8
Q

Define what is meant by total lung capacity.

A

The total volume of air in lungs after maximum inspiration.

Sum of all volumes (~6L)

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9
Q

Define what is meant by anatomical dead space.

A

The volume of air that never reaches the alveoli and so never participates in respiration.

Includes volume in upper and lower respiratory tract, including the terminal bronchioles.

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10
Q

Define what is meant by alveolar dead space.

A

The volume of air that reaches the alveoli but never participates in respiration.

This can reflect alveoli that are ventilated by are not perfused, for example secondary to pulmonary embolus.

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11
Q

What can be measured using simple spirometry?

A
  • tidal volume
  • inspiration reserve volume
  • expiratory reserve volume

Measured values are standardised for height, age and sex. Of these, height is the factor with the greatest influence upon capacities.

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12
Q

Outline how spirometry is performed.

A

The patient is asked to take a maximum inspiration, and then breathe out as quickly as possible.

Results are often presented as volume-time curves.

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13
Q

Give the four patterns that can be identified using spirometry.

A
  1. Normal spirometry
  2. Restrictive spirometry
  3. Obstructive spirometry
  4. Mixed obstructive and restrictive picture
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14
Q

Give the spirometry findings that would be consistent with each of the following patterns:

a) normal spirometry

b) restrictive spirometry

c) obstructive spirometry

d) mixed obstructive and restrictive picture

A

a) normal FEV1, FVC and FEV1/FVC ratio

b) reduced FVC but a normal FEV1/FVC ratio (as FEV1 decreases proportionately)

c) reduced FEV1 and FVC (but to a lesser extent than FEV1), therefore FEV1/FVC ratio reduced (<0.7)

d) FVC is reduced AND FEV1/FVC ratio reduced

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15
Q

What is meant by bronchodilator reversibility in relation to spirometry?

A

If there is a ‘reversible’ airway obstruction, there will be an improvement in the FEV1/FVC ratio after administering a dose of bronchodilator.

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16
Q

What instructions do you give to a patient when asking them to measure PEFR?

A
  1. Ensure the peak flow meter is set to zero.
  2. Position yourself sitting up straight or standing.
  3. Take the deepest breath you are capable of.
  4. Hold the peak flow meter parallel to the floor and position your mouth around the mouthpiece of the peak flow meter, creating a tight seal with your lips.
  5. Exhale as forcefully as you are able to.
  6. Note the reading on the peak flow meter, which is measured in litres per minute.
  7. Repeat steps 1-6 twice more.
  8. The highest reading of the three attempts should be used as the final result.
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17
Q

What is the purpose of peak flow meters?

A

A device used to measure PEFR, to identify changes in peak flow and thus changes to airway obstruction.

During a diagnosis of asthma, it is common to ask patients to monitor their peak flow at least twice daily for 2-4 weeks.

As part of long term monitoring of asthma, it is common to ask patients to check their PEFR regularly.

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18
Q

What is the exhaled nitric oxide test (FeNO)?

A

A newer test that measures nitric oxide levels in exhaled breath.

Levels of nitric oxide are increased when there is active airway inflammation, as occurs in asthma.

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19
Q

What are the disadvantages of FeNO?

A

Levels of nitric oxide can be affected by smoking and inhaled corticosteroids (reduce the level).

FeNO not always raised in people with asthma.

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20
Q

What are the different types of inhaler?

A

a) MDIs - pressurised metered dose inhaler: generates and aerosol that is inhaled.

b) DPIs - dry powdered inhaler: the dry powder is inhaled.

c) SMIs - soft mist inhaler: the soft mist is inhaled.

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21
Q

Salbutamol:

a) drug class

b) MOA

c) adverse effects

d) contraindications

e) interactions

A

a) SABA

b) agonises B2 receptors in the airways, causing bronchodilation and increasing mucociliary clearance of mucus.

c) tachycardia; angina; palpitations; anxiety; tremor; glycogenolysis

d) CVD

e) beta-blockers may antagonise SABA

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22
Q

Salmeterol:

a) drug class

b) MOA

c) adverse effects

d) contraindications

e) interactions

A

a) LABA

b) agonises B2 receptors in the airways, causing bronchodilation and increasing mucociliary clearance of mucus.

c) tachycardia; angina; palpitations; anxiety; tremor; glycogenolysis

d) mask airway inflammation (therefore only prescribe alongside ICS)

e) beta-blockers may antagonise LABA

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23
Q

Tiotropium bromide

a) drug class

b) MOA

c) adverse effects

A

a) LAMA

b) antagonises muscarinic airway receptors, blocking parasympathetic mediated contraction of airway smooth muscle.

c) dry mouth; urinary retention; dry eyes

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24
Q

Ipratropium bromide:

a) drug class

b) MOA

c) adverse effects

A

a) SAMA

b) antagonises muscarinic airway receptors, blocking parasympathetic mediated contraction of airway smooth muscle.

c) dry mouth; urinary retention; dry eyes

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25
Q

Beclometasone:

a) drug class

b) MOA

c) adverse effects

d) contraindications

A

a) inhaled corticosteroid

b) ICS pass through plasma membrane and activates cytoplasmic receptors, reducing airway inflammation and causing bronchodilation.

c) oral candidiasis; horse voice

d) high doses + COPD = pneumonia

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26
Q

Monteleukast:

a) drug class

b) MOA

c) adverse effects

A

a) leukotreine receptor antagonist (LTRA)

b) blocks CystLTR1, reducing the secretion of leukotrienes. This prevents bronchoconstriction and decreases mucus secretion.

c) headache; GI disturbances; dry mouth

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27
Q

What are the common combinations of drugs used in inhalers?

A

a) ICS + LABA (asthma and COPD)

b) LABA + LAMA (COPD)

c) ICS + LABA + LAMA (COPD)

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28
Q

What is asthma?

A

A chronic respiratory condition associated with airway inflammation and hyper-responsiveness.

This causes bronchospasms, bronchial oedema and airway obstruction.

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29
Q

What symptoms should make me suspect asthma?

A
  • wheeze
  • cough
  • breathlessness
  • chest tightness

Symptoms are commonly episodic and diurnal (ie. worse at night or in the early morning).

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30
Q

What are some triggers for asthma?

A
  • exercise
  • viral infection
  • exposure to cold air
  • allergens

In children, symptoms may also be triggered by emotion or laughter.

In adults, symptoms may also be triggered by use of NSAIDs and beta blockers.

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31
Q

List some high-risk occupations for occupational asthma.

A
  • laboratory work
  • baking
  • animal handling
  • welding
  • paint spraying

Check for possible occupational asthma by asking:

  • are symptoms better on days away from work?
  • are symptoms better when on holiday
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32
Q

A family history of atopy is a risk factor for asthma. Give the three components of the triad of atopy.

A
  1. Atopic eczema
  2. Allergic rhinitis
  3. Asthma
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33
Q

Which FeNO results would be consistent with a diagnosis of asthma in people aged 17 years or older?

A

Asthma causes airway inflammation, which can cause nitric oxide levels to rise in the airway.

Therefore, a raised FeNO >40ppb is considered a positive result.

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34
Q

Which FeNO results would be consistent with a diagnosis of asthma in people aged 16 years or younger?

A

Only use FeNO in ages 5-16years if there is diagnostic uncertainty after initial assessment.

A raised FeNO >35ppb is considered a positive result.

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35
Q

Give the:

a) positive predictive value

b) negative predictive value

of FeNO testing.

A

a) 80% (1 in 5 will not have asthma, despite a positive FeNO)

b) 80& (1 in 5 will have asthma, despite a negative FeNO)

The results of FeNO may be affected by empirical treatment with inhaled corticosteroids.

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36
Q

Which spirometry results would be consistent with a diagnosis of asthma in people aged 17 years or older?

A

FEV1/FVC <70% (obstructive pattern)

FEV1/FBC BDR improvement ≥12%.

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36
Q

Which spirometry results would be consistent with a diagnosis of asthma in patients?

A

FEV1/FVC <0.7 (obstructive pattern)

Should be offered to all symptomatic people over the age of 5 years.

37
Q

Which bronchodilator reversibility (BDR) results would be consistent with a diagnosis of asthma?

A

An improvement of >12% in response to SABA or corticosteroids is regarded as a positive result and is strongly suggestive of asthma.

38
Q

Which peak flow variability testing results would be consistent with a diagnosis of asthma?

A

Supports a diagnosis of asthma if there is diagnostic uncertainty after initial assessment.

A value of more than 20% variability after monitoring at least twice daily for 2-4 weeks is regarded as a positive result.

PEF variability is usually calculated as the difference between the highest and lowest readings, expressed as a percentage of the average PEF.

39
Q

What is the first line treatment for asthma?

A

Offer a SABA (e.g. salbutamol) as reliever therapy to adults with newly diagnosed asthma.

Offer a low dose ICS as first-line maintenance therapy to adults with:

  • symptoms at presentation that clearly indicate the need for maintenance therapy (e.g. asthma 3x/week, causing waking at night)
  • symptoms that are uncontrolled by SABA alone
40
Q

If asthma is uncontrolled on a low dose of ICS as maintenance therapy, what is the next step in management?

A

Offer a LABA (e.g. salmeterol) with ICS.

If symptoms persist can consider LTRA (e.g. monteleukast).

41
Q

If asthma is uncontrolled on a low dose of ICS and LABA as maintenance therapy, what is the next step in management?

A

Offer a LTRA in combination with the ICS, and consider review LTRA treatment:

  • discuss whether to continue LTRA treatment
  • take into account degree of response to LTRA treatment
42
Q

LABA must always be prescribed in combination with ICS - why?

A

LABA may mask airway inflammation so should always be prescribed alongside ICS.

43
Q

If asthma is uncontrolled on a low dose of ICS and LABA as maintenance therapy, what is the next step in management?

A

Offer to change ICS and LABA maintenance therapy to a maintenance and reliever therapy (MART).

MART consists of a single inhaler containing both ICS and a fast-acting LABA, so is used for both maintenance therapy and relief of symptoms as required.

44
Q

How many times should ICS / SABA inhalers be used in a day?

A

ICS - one puff twice daily

SABA - use p.r.n. (2 puffs 3-4 times a day)

45
Q

How can the side effect of oral thrush be avoided if using ICS as asthma maintenance?

A

Rinse mouth with water or mouthwash after use.

46
Q

How is asthma diagnosed?

A

No single diagnostic test - use a mixture of signs and symptoms, along with respiratory tests:

  • spirometry with bronchodilator reversibility
  • PEFR
  • FeNO

If under the age of 5 years, it may be difficult to undertake the diagnostic respiratory tests. The tests should be carried out at age 5 if they have previously presented with asthma signs / symptoms.

47
Q

What is the order that objective asthma tests should be carried out in:

a) adults?

b) children?

A

a) FeNO, then BDR spirometry, then peak flow variability, then direct bronchial challenge.

b) BDR spirometry, then FeNO if uncertainty, then peak flow variability.

48
Q

Suggest some red flag signs that would make you suspect an alternative diagnosis to asthma.

A
  • persistent, non-variable breathlessness
  • chronic sputum production
  • unexplained restrictive spirometry
  • nasal polyps
49
Q

What is the aim of asthma management?

A

Complete control of asthma symptoms, which is achieved when:

  • no daytime symptoms
  • no night-time waking due to asthma
  • no need for rescue medication
  • no asthma attacks
  • no limitation on activity including exercise
  • normal lung function
  • minimal side effects from medication
50
Q

Apart from pharmacological asthma management, what other management options are there for asthmatic patients?

A
  • assess baseline asthma status (e.g. questionnaires or lung function tests)
  • provide self-management education and a personalised asthma action plan
  • provide sources of information (e.g. Asthma UK / British Lung Foundation)
  • provide advice on weight loss, smoking cessation and breathing exercises
  • monitor using peak flow variability
  • avoid any triggers
  • review
51
Q

What is a personalised asthma action plan?

A

Every patient with asthma should receive a personalised asthma action plan. This tells the patient:
- what medicines to take every day to prevent symptoms
- what to do if asthma symptoms are getting worse
- what to do in an emergency if having an asthma attack

52
Q

How should a person with asthma be followed up?

A

Annual reviews, checking:
- peak flow or spirometry
- inhaler technique
- symptoms including control
- calculate future risk of asthma attacks

Note if patient is on long-term steroid tablets, cholesterol, HbA1c, vision check and BP should also be checked annually.

53
Q

When should you consider giving oral macrolides to prevent exacerbations in asthma?

A

Patients aged 50-70yo with ongoing symptoms, despite high-dose inhaled steroids AND have suffered one exacerbation requiring oral steroids in the previous year

This is used to try to reduce exacerbation frequency.

Treatment with azithromycin 500mg 3x/week for minimum 6/12.

54
Q

How can asthma control be assessed during an annual asthma review?

A

Use Royal College of Physicians three questions:

  1. “Have you had difficulty sleeping because of your asthma symptoms (including cough)?”
  2. “Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?”
  3. “Has your asthma interfered with your usual activities (e.g. housework, work, school)?”

Answering no to all three questions suggest asthma control.

55
Q

Give some examples of medications in the following categories:

a) SABA

b) LABA

c) SAMA

d) LAMA

e) ICS

A

a) salbutamol, terbutaline sulfate

b) salmeterol, formoterol

c) ipratropium bromide

d) tiotropium bromide

e) beclomethasone, budesonide, fluticasone

56
Q

What are the 4 steps of asthma self management?

A
  • track symptoms, arranging an asthma review if any changes
  • measure peak flow regularly
  • take preventer medications
  • follow asthma self-management plan
57
Q

What are the two main sub-categories of asthma attacks?

A
  • acute severe asthma
  • life-threatening asthma
58
Q

Give the signs and symptoms of acute severe asthma attack, including:

a) PEFR

b) SpO2

c) Resp rate

d) Pulse

A

Cannot speak in full sentences and wheeze upon auscultation of the chest.

a) 33-50%

b) ≥92%

c) ≥25/min

d) ≥110bpm

59
Q

Give the signs and symptoms of life-threatening attack, including:

a) PEFR

b) SpO2

c) Resp rate

d) Pulse

A

Cannot speak in full sentences and wheeze upon auscultation of the chest.

a) PEFR <33%

b) SpO2 <92%

c) low (agonal sign)

d) low (agonal sign)

60
Q

What is the treatment in primary care for:

a) acute severe asthma exacerbation

b) life-threatening asthma exacerbation

c) while awaiting admission to hospital

A

a) give bronchodilator treatment; admit to hospital if no improvement

b) admit to hospital

c) controlled supplementary oxygen; nebulised salbutamol; if salbutamol not effective consider nebulised ipratropium bromide.

Note if no nebuliser use MDI with spacer.

61
Q

Give the two components of chronic obstructive pulmonary disease (COPD).

A
  • emphysema
  • chronic bronchitis
62
Q

How does COPD lead to increased airway resistance?

A

a) luminal obstruction of airways by secretions
b) narrowing of small bronchioles

NB: This promotes hyperinflation of the lungs (ie. barrel chest) as expiratory force is reduced, leading to air trapping.

63
Q

What is COPD?

A

A disease state characterised by airflow limitation that is not fully reversible, encompassing emphysema and chronic bronchitis.

64
Q

What is the main cause of COPD?

A

Smoking accounts for approx. 90% of cases.

65
Q

A young patient, with no history of smoking, presents with emphysematous dominant COPD. What is the most likely cause?

A

Alpha-1 antitrypsin deficiency.

A deficiency results in destruction of the alveolar walls and thus loss of elastic recoil / dilated air spaces.

66
Q

Which physiological changes to the airways are observed in chronic bronchitis dominant COPD?

A
  • ciliary dysfunction
  • hyerplasia of goblet cells, resulting in hypersecretion of mucus
67
Q

Which physiological changes to the airways are observed in emphysematous dominant COPD?

A
  • elastic breakdown leading to destruction of alveolar walls and structure, and loss of elastic recoil
  • loss of small airways / formation of large airways (reduced SA:V ratio)
68
Q

Why is airway obstruction in COPD and asthma most impeded during expiration?

A

The narrowing of airways in COPD and asthma is exacerbated when, during expiration, the rising intrathoracic pressure exerts increased pressure on the narrow airways. This further decreases the lumen of the airways, impeding airflow through them.

69
Q

What is the pathophysiology of COPD secondary to smoking?

A
  • cigarette smoke causes chronic inflammation
  • oxidative injury of the airways causes physiological changes
70
Q

What are some risk factors for COPD?

A
  • smoking (passively) (accounts for approx 90%)
  • occupational exposure (e.g. coal, silica)
  • air pollution
  • alpha-1 antitrypsin deficiency
  • maternal smoking
  • preterm birth
  • asthma
71
Q

Presentation of COPD.

A

Symptoms:
- breathlessness (progressive; worse on exertion)
- chronic or recurrent cough
- sputum production
- frequent LRTI
- wheeze

Signs:
- cyanosis
- use of accessory respiratory muscles
- hyperinflation of chest (ie. barrel chest)
- cachexia
- wheeze / crackles upon auscultation
- raised JVP or peripheral oedema (cor pulmonale)

72
Q

Which spirometry results would be consistent with a diagnosis of COPD in people aged 17 years or older?

A
  • FEV1/FVC <0.7

BDR has <12% improvement for ratio.

73
Q

What is cor pulmonale and when should you suspect it?

A
  1. Chronic hypoxia results in hypoxic vasoconstriction
  2. Pulmonary hypertension increases afterload for right ventricle
  3. Right ventricle hypertrophies and eventually fails

Suspect if:
- peripheral oedema
- raised JVP
- systolic parasternal heave
- hepatomegaly

74
Q

What investigations should you arrange if you suspect a patient has COPD?

A
  • CXR (exclude cancer, bronchiectasis)
  • FBC (anaemia; polycythaemia)
  • spirometry (obstructive pattern)
75
Q

Give some differential diagnoses for COPD.

A
  • asthma
  • bronchiectasis
  • heart failure
  • lung cancer
  • interstitial lung disease
  • tuberculosis
  • anaemia
  • cystic fibrosis
76
Q

Give some possible complications of COPD.

A
  • exacerbations of COPD
  • cor pulmonale
  • respiratory failure
  • depression / anxiety
  • lung cancer
  • frequent chest infections
77
Q

What are the aims of treatment in COPD?

A
  • reduce symptoms
  • reduce exacerbations
  • improve quality of life
  • prevent deterioration of lung function
78
Q

What non-pharmacological management should be offered to COPD patients?

A
  • reinforce importance of healthy diet and lifestyle
  • smoking cessation advice
  • offer pneumovax and flu vaccinations
  • offer pulmonary rehabilitation
  • develop personalised self-management plan
79
Q

What is pulmonary rehabilitation?

A

An individually tailored programme for people with COPD, including exercise training, education, nutritional, psychological and behavioural interventions.

Do NOT refer people who are unable to walk or those with unstable angina.

80
Q

What pharmacological therapy (ie. inhalers) can be offered to patients with COPD?

A
  1. SABA or SAMA
  2. LABA + LAMA (SABA reliever) if no asthmatic features
  3. LABA + ICS (SABA reliever) if asthmatic features
81
Q

Aside inhalers, what other pharmacological therapy can be offered to COPD patients?

A
  • prophylactic antibiotics (e.g. azithromycin)
  • mucolytic treatment (e.g. carbocisteine)
  • oral theophylline
  • oxygen
82
Q

When should you suspect an acute exacerbation of COPD?

A
  • increase sputum volume / purulence
  • cough
  • wheeze
  • fever
  • URTI
  • increased resp rate or heart rate
83
Q

Give 5 indications where you would consider hospital admission for a patient with an acute COPD exacerbation.

A
  1. Severe breathlessness
  2. Inability to cope at home / living alone
  3. SpO2 <90%
  4. Confusion or impaired consciousness
  5. Cyanosis
84
Q

When awaiting transfer to hospital with a patient who is having an acute exacerbation of COPD, what is the management?

A

Give oxygen aiming for SpO2 88-92%

85
Q

Why is SpO2 target set at 88-92% in COPD patients?

A

In chronically hypoxaemic patients (ie. COPD), excess SpO2 carries a risk of dangerous hypercapnia (ie. via Haldane effect).

Haldane effect: Deoxygenated haemoglobin has a higher affinity for CO2, so carbamino compounds are produced in venous blood.

At the lungs, Hb becomes saturated with O2 and displaces CO2. pCO2 rises and it diffuses down its partial pressure gradient into the alveoli.

86
Q

What is end-stage COPD?

A

When people have severe and worsening symptoms, quality of life and functional level, this is end-stage COPD.

Acute exacerbations are more common and there is an increased risk of death.

87
Q

Give some causes of obstructive lung disease.

A
  • COPD
  • asthma
  • emphysema
  • bronchiectasis
  • cystic fibrosis
88
Q

Give some pulmonary causes of restrictive lung disease.

A
  • pulmonary fibrosis
  • pneumoconiosis
  • pulmonary oedema
  • pneumonectomy
  • parechymal lung tumour
89
Q

Give some non-pulmonary causes of restrictive lung disease.

A
  • skeletal abnormalities (e.g. kyphoscoliosis)
  • neuromuscular disease (e.g. motor neuron disease, myasthenia gravis)
  • connective tissue disease
  • obesity
  • pregnancy

Year 3 - GP (17 decks)

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